Human Factors Techno- logy Medicine 2009 © Xiao, UM Course Objectives 1.Review concepts and theories of coordination in literature 2.Characterize problems and issues of coordination and workflow in healthcare 3.Review of case studies in healthcare

Human Factors Techno- logy Medicine 2009 © Xiao, UM Yan Xiao, PhD Professor of Anesthesiology Director, Research in Patient Safety University of Maryland School of Medicine Baltimore, Maryland, USA

Human Factors Techno- logy Medicine 2009 © Xiao, UM 2006 National Health Spending: $2.1 Trillion $7,026/person 16% of Gross Domestic Product (GDP) Challenges of Coordination in Healthcare

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination in Healthcare: How it matters #1 priority for research: "Lack of communication and coordination (including coordination across organisations and discontinuity)" ( British Medical Journal 2009 ) Poor coordination results in: Low quality and efficiency Errors in medication and treatment Conflicting information

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination and mortality Medicare mortality lower among hospitals known for good nursing care - particularly the ability to coordinate across units Source: Aiken, Sochalski, and Lake, Medical Care, 1997.

Human Factors Techno- logy Medicine 2009 © Xiao, UM Shortell, Zimmerman and Rousseau et al. Medical Care, Coordination and Quality National Study of 42 Intensive Care Units Nursing leadership, ability to manage conflict, and better care coordination positively associated with lower risk- adjusted length of stay, lower nurse turnover, better evaluated technical quality of care and ability to meet family member needs.

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination and surgical outcomes A study of 3,000 CABG patients in 16 hospitals A group-oriented, collaborative, participative culture was significantly associated with higher patient physical and mental functional health status scores six months post-discharge and shorter post- operative intubation times. Shortell, Jones, Rademaker, and Gillies et al

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination and quality In a nine hospital study of patients with total hip and total knee replacement, relational coordination was significantly associated with less post-operative pain, greater post-operative functioning, and shorter length of stay. Source: J. Gittel, K. Fairfield, and B. Bierbaum, et al. “Impact of Relational Coordination on Quality of Care, Post-Operative Pain and Functioning and Length of Stay,” Medical Care, 2000, 38(3):

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination in Healthcare How it matters Highly inter-dependent activities –Care is usually provided by multiple care providers over time at distributed locations –Care needs are episodic and unpredictable –Highly variable patient needs

Human Factors Techno- logy Medicine 2009 © Xiao, UM What Does Coordination Mean? (or Not*) Have what is need –“Medical record missing information had to wait for info to complete both surgical & anesthesia consent.” –Case delayed 35 min. Have the correct information –“Final printed posting was changed from the correct original posting. Change did not reflect the correct surgery. All supplies and instrument trays were wrong.” –Case delayed 40 min. Have the “left hand” to know what the “right hand” is doing –“Both Dr L and Dr R were scheduled for case. Dr L thought Dr R was to start and Dr R thought Dr. L would start. Dr L was scheduled for another 1st case, when contacted he stated he was the consult on the case.” –Case delayed 1 hr 45 min. Have the most current information –“OR front desk did not know pt was on 10 W.” Case delayed 15 min. *Reports courtesy of Kate Bott and Mike Harrington

Human Factors Techno- logy Medicine 2009 © Xiao, UM Trajectories Phenomenon definition: multiple people working on multiple “projects”, over long span of time and distances Problem definition: how people manage different trajectories

Human Factors Techno- logy Medicine 2009 © Xiao, UM Examples of Trajectories Care activities for a surgical patient –Patient admission –Preparation of documents, supplies, personnel –Start and end of surgery –Post anesthesia care and intensive care –Recovery and rehabilitation –Discharge

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination in Healthcare What it is: Trajectory” of Patient Care Admission Diagnosis (MRI, CT, ETC) Surgery Stabilization Assessment + Disposition Discharge Primary Team Consulting physicians O.T., P.T. Social worker Transporter

Human Factors Techno- logy Medicine 2009 © Xiao, UM Patient with Traumatic Brain Injury

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination in Healthcare What it is: the example of car crashes Time 0: two cars collided Landmark 1: Emergency medical services system activated Landmark 2: Patients extricated and placed on ambulances Landmark 3: Patients arrived at trauma center Landmark 4: Patients received definitive surgical care

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination saves lives Coordination challenges in emergency medical services (EMS) Field Command center Hotline Notification Board Trauma Resuscitation Unit Landing pad Operating room

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination in Healthcare What it is: A broad definition Objects of coordination: what to coordinate –Information –Mental models –Expectations –Expertise –Authorities –Relations –Tasks

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination in Healthcare What it is: A broad definition Means of coordination: how to coordinate –Explicit versus implicit –Low versus high bandwidth –Routine versus mutual adjustment mechanisms –Spontaneous versus reactive

Human Factors Techno- logy Medicine 2009 © Xiao, UM Summary Coordination is a key challenge for healthcare, because of –Variations –Uncertainties –Distribution The objects of coordination include tasks, information, authorities, expectations

Human Factors Techno- logy Medicine 2009 © Xiao, UM

Human Factors Techno- logy Medicine 2009 © Xiao, UM University of Maryland Medical Center and Shock Trauma Center 32 operating rooms, 6 dedicated to trauma 10 trauma bays 7000 annual trauma patient admissions

Human Factors Techno- logy Medicine 2009 © Xiao, UM Studies of Coordination at University of Maryland Healthcare context for coordination studies –Trauma resuscitation: Action teams –Operating rooms: Operations management of surgical services –Intensive care units: transfers of information and responsibilities Perspectives of understanding coordination –Social system of relations and conflicts –CSCW system of computing and cognition –Economic system of efficiency –Workflow system of activity and materials

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination Studies: Experience at University of Maryland Coordination in high intensity team (HIT) situation –Adaptive team structures (Xiao 2005) –Dynamic delegation and leadership (Klein 2006)

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination Studies: Experience at University of Maryland Orchestrating information flow in ICU –Structures of rounding communication (Cardarelli in press) –Preparing for team meetings (Cervenka in revision) –Reaching and communicating goals in team meetings (“rounds”) (Xiao in review) –Information arena model of team communication

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination Studies: Experience at University of Maryland Managing workflow in operating suites –Communication burden of coordinators (Moss 2004) –Distributed coordination through OR video (Xiao 2005) –Acceptance and usage of OR video (Xiao 2007) –Visual versus table display of procedural duration uncertainty (Dexter, Ho 2008)

Human Factors Techno- logy Medicine 2009 © Xiao, UM Coordination Studies: Experience at University of Maryland Exception handling in trauma patient care –Discharge rounds (Sen 2008)

Human Factors Techno- logy Medicine 2009 © Xiao, UM Summary Healthcare is a fertile domain to develop theories and concepts of coordination Different types of coordination problems facing care providers in different contexts

Human Factors Techno- logy Medicine 2009 © Xiao, UM HeadCam Pan-Tilt-ZoomCam Ceiling Mic IR Duplex Audio